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Abstract
Purpose:
To determine the CT findings of immediately postoperative complications including anastomotic leakage, and to evaluate the usefulness of CT scan in the assessment of early postoperative complications of pylorus preserving Whipple pancreaticoduodenectomy (PPPD)
Materials and Methods:
During the early postoperative period, fluid accomulated in the abdominal cavity of ten of 23 patients who had undergone PPPD. In all cases, the time interval between the first follow up CT scan and surgery was no more than two weeks. At each leakage site, we compared CT findings with those of conventional fluoroscopic studies: upper gastrointestinal studies with oral water-soluble contrast materials, a contrast injection study via drainage catheters in place in the stomach, the site of choledochojejunostomy during surgery and pancreaticojejun- ostomy, and nine cases of sinogram via percutaneous drainage catheters. We also evaluated CT findings of the locations, amounts, and margin of the fluid collections. If conventional fluoroscopic studies showed no evidence of anastomotic leakage, as was the case with six patients, the leakage site was determined on the basis of clinical and laboratory data. In four of the six, this was found to be the site of pancreaticojejunostomy, and in the other two, an abscess without anastomotic leakage
Results:
Eight patients showed intra-abdominal fluid collections due to leakage at anastomotic sites: in five, this was the site of pancreaticojejunostomy, and in three, that of choledochojejunostomy. One patient showed a right subphrenic abscess, and another, a loculated fluid collection between the jejunal loops, without leakage at the anastomotic site. CT scans in all three cases with leakage at the site of choledochojejunostomy showed the small collection of fluid to be relatively well demarcated and confined to the areas of lesser sac or gallbladder bed. In four of five cases of leakage at the site of pancreaticojejunostomy, the large collection of fluid was widespread å it occupied areas which included the perihepatic and peripancreatic space, as well as the paracolic gutters and pelvic cavity.
Conclusion:
In some cases of suspected complications arising after PPPD, and including anastomotic leakage and abdominal abscess, leakage is not revealed by conventional fluoroscopic studies å in such cases, CT scanning may help detect the complications and determine the site of anastomotic leakage.
REFERENCES
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Fig. 1.
A 69-year-old man with leakage at the site of pancreaticojejunostomy 2 weeks after pylorus-preserving Whipple pancreaticoduodenectoy for the malignancy in the pancreatic head. The leakage of the site of pancreaticojejunostomy is determined by clinical data. A. At the level of the splenic hilum, CT scan shows widespread fluid collections in the perihepatic, perisplenic space and lesser sac. B. CT scan 12cm inferior to Β shows fluid collection in both paracolic gutters. C. CT scan 5cm inferior to C shows large amount fluid collection in the pelvic cavity D. Fluoroscopic study with contrast injection through the percutaneous transhepatic biliary drainage catheter can not reveals the site of pancreaticojejunostomy and leakage at this site.
Fig. 2.
A 52-year-old man with leakage at the site of choledochojejunostomy 1 week after pylorus preserving Whipple pancreaticoduodenectomy for the malignancy of the pancreatic head. The leakage site is determine! by conventional fluoroscopic study. A. CT scan reveals well demarcated fluid collection at the lesser sac. B. Fistulogram through the percutaneous drainage catheter reveals communication of abscess cavity with the biliary trees.
Tabel 1.
CT Findings of the Fluid Collection as to Leakage Sites
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